Republished review: Mitral regurgitation in patients with aortic stenosis undergoing valve replacement.

Mitral regurgitation is a frequent finding in patients with aortic stenosis scheduled for aortic valve replacement. Detection of mitral regurgitation in such patients has important implications, as it can independently affect functional status and prognosis. When mitral regurgitation is moderate to severe, a decision to operate on both valves should only be made following a careful clinical and echocardiographic assessment. Indeed, double-valve surgery increases perioperative and postoperative risks, and mitral regurgitation may improve spontaneously after isolated aortic valve replacement. Better understanding of the determinants of these changes appears particularly crucial in the light of recent advances in percutaneous aortic valve replacement.

[Pseudoaneurysm of the ascending aorta. Rare complication following aortic valve replacement]. / Faux anévrisme de l'aorte ascendante. Complication rare d'une chirurgie valvulaire aortique.

False aneurysm of the ascending aorta has been reported as a rare complication of cardiovascular surgery among which the etiology, the physiopathology and the natural evolution are still badly known. The diagnosis is often fortuitous. The clinical polymorphism of the affection imposes the appeal to the morphological explorations to establish an early diagnosis and determine the adequate therapeutic attitude. This complication of the cardiac surgery is associated with a high mortality in spite of the cardiovascular surgery progress. In this report, we present a case of a pseudoaneurysm of the ascending aorta which was discovered six months after aortic valve replacement for severe aortic stenosis. We discuss in this article the diagnostic and therapeutic aspects of this case.

Impact of prosthesis-patient mismatch on mitral regurgitation after aortic valve replacement.

BACKGROUND: Mitral regurgitation is frequently observed in patients undergoing aortic valve replacement (AVR) for aortic stenosis and often improves postoperatively, mainly due to left ventricular remodelling and changes in loading conditions. Aortic prosthesis-patient mismatch (PPM) is associated with poor outcome and lesser left ventricular remodelling. This study tested the hypothesis that aortic PPM affects mitral regurgitation. METHODS AND RESULTS: Echocardiography was performed preoperatively and before discharge in 42 patients with aortic stenosis undergoing isolated AVR and presenting mitral regurgitation with an effective regurgitant orifice (ERO) of 10 mm(2) or greater, as assessed by the proximal isovelocity surface area method. Postoperatively, mitral ERO and the regurgitant volume decreased from 16±5mm(2) to 12±6mm(2) (p<0.001) and from 28±8ml to 16±9ml (p<0.0001), respectively. PPM (indexed effective prosthetic valve area (EOAi) ≤0.85cm(2)/m(2)), present in 23 patients (55%), was associated with a smaller decrease in regurgitant volume (p=0.0025) and ERO (p=0.02). A functional aetiology of mitral regurgitation was associated with a larger improvement in mitral regurgitation. In the whole cohort, EOAi correlated with the changes in mitral regurgitation severity (ERO r=0.44, p=0.01; regurgitant volume r=0.47, p=0.003). However, these relationships were no longer significant in the subset of patients with functional mitral regurgitation in whom mitral regurgitation changes were mainly related to postoperative changes in mitral valve deformation. CONCLUSIONS: The presence of PPM after AVR attenuates postoperative mitral regurgitation changes, mainly in patients with organic mitral regurgitation.

Mitral regurgitation in patients with aortic stenosis undergoing valve replacement.

Mitral regurgitation is a frequent finding in patients with aortic stenosis scheduled for aortic valve replacement. Detection of mitral regurgitation in such patients has important implications, as it can independently affect functional status and prognosis. When mitral regurgitation is moderate to severe, a decision to operate on both valves should only be made following a careful clinical and echocardiographic assessment. Indeed, double-valve surgery increases perioperative and postoperative risks, and mitral regurgitation may improve spontaneously after isolated aortic valve replacement. Better understanding of the determinants of these changes appears particularly crucial in the light of recent advances in percutaneous aortic valve replacement.

Rescue extracorporeal circulation as bridge to recovery in fulminant cocaine-induced heart failure.

Cocaine is an increasing cause of admission in the emergency room. The widespread abuse of this drug during the last decade in the USA is now widely emerging in Europe. Because of its various cardio-vascular complications, cocaine is one of the most death-related drugs known at this time. The following report describes the dramatic case of a young man polydrug addict presenting at our institution with life-threatening acute heart failure that developed shortly after his very first cocaine intake. Because of the lack of response to intensive medical treatment, we decided to perform a percutaneous extracorporeal circulation membranous oxygenation (ECMO) that allowed survival and rapid left ventricular function recovery. This report highlights cocaine as a rising trigger of acute heart failure in young people and is, to the best of our knowledge, the first report that illustrates ECMO as an effective hemodynamic support in the course of fulminant cocaine-induced cardiomyopathy.

[Acute myocarditis: from chest pain to cardiogenic shock]. / Les myocardites aiguës: de la douleur thoracique au choc cardiogénique--a propos de trois cas.

We report the observations of three patients with myocarditis. The first one with chest pain, the second one with a pseudo-infarct presentation and the third one with a cardiogenic shock. We discuss the different anatomo-clinical presentations of myocarditis, the diagnosis, the indications of endomyocardial biopsies and the prognosis of this pathology.

Cardiac and autonomic evaluation in a pediatric population with human immunodeficiency virus.

BACKGROUND: Cardiac involvement in children with human immunodeficiency virus (HIV) infection is a well-known entity and occurs clinically more often in patients with advanced acquired immunodeficiency syndrome (AIDS). Autonomic dysfunction is less known, especially in children. HYPOTHESIS: The aim of this study was to asses the prevalence of cardiovascular abnormalities in a pediatric population with HIV. We also aimed to evaluate whether autonomic involvement occurs in the same population and is dependent on echocardiographic abnormalities. METHODS: The occurrence of echocardiographic abnormalities was evaluated in 22 children with HIV infection, and five noninvasive tests were performed to evaluate the presence of autonomic dysfunction. RESULTS: We found cardiac lesions in four children (18%), consisting of pericardial effusion in three children, wall motion abnormalities in three children, and acute aortic endocarditis in one child. All cardiac abnormalities were found at Stage C by Center for Disease Control (CDC) revised classification. We also found left ventricular filling pattern abnormalities consisting of E-wave maximal velocity decrease and prolonged deceleration time compatible with diastolic dysfunction. One of the five autonomic tests (Valsalva maneuver) was significantly altered, even in patients without abnormal echocardiography, suggesting mild autonomic dysfunction. CONCLUSION: The study demonstrated a high prevalence of cardiac lesions in children with HIV infection and indicated the presence of autonomic dysfunction even when there are no echocardiographically detected abnormalities.

Quantification of mitral regurgitation by the automated cardiac output method: an in vitro and in vivo study.

BACKGROUND: Recently, the automated cardiac output method (ACM) was introduced for the calculation of blood flow at the left ventricular outflow tract (LVOT). This study was performed to examine the possibility of using ACM for flow calculation at the level of the mitral valve and for the quantification of mitral regurgitation (MR) in vitro and in vivo. METHODS AND RESULTS: In a computer-controlled in vitro model of the human heart, aortic and mitral normal bioprosthetic valves were inserted. ACM and electromagnetic probe flow measurements correlated well at the LVOT and at the mitral level (r2 = 0.79 and 0.77, respectively). For stroke volumes ranging from 30 to 100 ml/beat, there was no statistically significant bias between ACM and electromagnetic flow probe (-1.5 and 1.3 ml for LVOT and mitral level, respectively). Limits of agreement were [-14; +11] ml and [-18; +16] ml, respectively. We evaluated 68 patients in our in vivo study. They were divided into three groups according to the results of "standard" echocardiographic Doppler methods for the semiquantification of MR: echocardiographic color Doppler cartography, intensity of the continuous wave Doppler spectra, and in some patients, pulmonary venous flow, conventional Doppler, and proximal isovelocity surface area quantitative data. Group 1 consisted of 35 patients without MR or a physiologic one; the 17 patients in group 2 had a mild MR (1-2/4) and in group 3, 16 patients with MR 3-4/4 were included. Regurgitant volume (RV) was calculated as the difference between ACM mitral flow and ACM aortic flow, and regurgitant fraction (RF) was defined as the ratio between RV and ACM mitral flow. When mitral flow was measured only from the four-chamber view, we found in group 1, RV = -0.57 (0.67) L/min and RF = -16% (19%); in group 2, RV = -0.31 (1.06) L/min and RF = -8% (19%); and in group 3, RV = 1.53 (0.94) L/min and RF = 23% (13%). RV and RF were statistically higher in group 3 compared with group 2 or group 1 (p < 0.0005), but no significant difference was found between groups 1 and 2. When mitral flow was measured by the mean value of ACM four-chamber and two-chamber views, this resulted in group 1, RV = -0.26 (0.63) L/min and RF = -8% (15%); in group 2, RV = 0.01 (1.04) L/min and RF = -2% (18%); and in group 3, RV = 2.07 (1.21) L/min and RF = 34% (19%). RV and RF were again significantly higher in group 3 (p < 0.0001). There was no significant difference between group 1 and group 2, but in group 1 RF was no longer statistically different from 0%. CONCLUSIONS: (1) In our in vitro setting, ACM is reliable both at the LVOT and at the mitral valve. (2) In the in vivo situation, some overlapping does exist between the three groups of MR. However, ACM is a very easy, rapid, and objective method to differentiate hemodynamic nonsignificant (<3/4) from significant (> or =3/4) MR. Together with other well-known methods for the quantification of MR, it should facilitate the gradation of MR in the clinical setting. The absence of significant differences between group 1 and group 2 proves that the accuracy of ACM measurements at the mitral valve needs to be ameliorated before ACM can be used as a gold standard for the noninvasive measurement of RV and RF.

Aortic valve aneurysm after acute endocarditis.

Endocarditis at the aortic level is usually characterized by the presence of a vegetation or an abscess on echocardiography. This paper reports on what is believed by the authors to be the first case of endocarditis presenting as an aneurysmal deformation of one aortic cusp without a vegetation.

Intracardiac thrombi associated with antiphospholipid antibodies.

Two cases of intracardiac thrombi associated with antiphospholipid antibodies are presented, one in the right atrium and the other in the left ventricle, the latter occurring in the presence of normal left ventricular function. In each, the diagnosis was made by transthoracic echocardiography. Both patients had contraindications to thrombolytic therapy and underwent successful surgical thrombectomy. We suggest that serial transthoracic echocardiography may be warranted in the follow-up of patients with primary hypercoagulable states.